Crash of a PAC 750XL in Cascais: 1 killed

Date & Time: Feb 12, 2010 at 1700 LT
Operator:
Registration:
D-FGOJ
Survivors:
Yes
Schedule:
Évora - Cascais
MSN:
139
YOM:
2008
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft departed Evora Airport in the afternoon for a local flight with two skydivers, one photographer and a pilot on board. Few minutes after take off, the photographer output a weapon and ordered both skydivers to jump. After they left the cabin, the photographer then threatened the pilot and ordered him to divert to Cascais-Tires Airport. After landing, the aircraft veered off runway, lost its undercarriage and came to rest in a grassy area near the apron. The pilot was able to escape while the photographer shot himself and died. Aircraft was damaged beyond repair, both wings being partially sheared off.
Probable cause:
Aircraft and crew hijacked in flight by a 'photographer'.
Final Report:

Crash of a Piper PA-31T-620 Cheyenne II in Forest City: 1 killed

Date & Time: Feb 12, 2010 at 1355 LT
Type of aircraft:
Operator:
Registration:
N250TT
Flight Type:
Survivors:
No
Schedule:
Chesterfield – Forest City
MSN:
31-7820050
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10352
Aircraft flight hours:
9048
Circumstances:
A witness reported that the multi-engine turboprop airplane was on final approach to land when it suddenly veered to the left and entered a rapid descent. The witness stated that he heard the "whine of the engines" before the airplane impacted terrain about 1/2 mile south of the runway threshold. In the days preceding the accident flight, the airplane had been at a maintenance facility to resolve a vibration in the rudder system while the autopilot system was engaged. There were no anomalies reported with the autopilot system during a test flight completed immediately before the accident flight. However, anomalies with the rate gyro were noted by a mechanic who recommended replacing it, but the pilot departed on the accident flight without the recommended repair having been completed. Further, examination of the autopilot annunciator panel indicated that the autopilot was likely not engaged at the time of impact, likely because the airplane was on a short final approach for landing. Accordingly, any existing autopilot faults would not have affected the flight as the autopilot system was likely not in use. There were no failures identified with the primary flight controls, engines, or propellers that would have prevented the pilot from maintaining control of the airplane manually. Toxicological testing revealed the presence of Zolpidem in the pilot's blood (Zolpidem, the trade name for Ambien, is used for short-term treatment of insomnia); however, the reported levels would likely not have resulted in any impairment.
Probable cause:
The pilot's failure to maintain airplane control during final approach.
Final Report:

Crash of a Cessna 425 Conquest I in Munich

Date & Time: Feb 2, 2010 at 0210 LT
Type of aircraft:
Operator:
Registration:
D-IAWF
Flight Type:
Survivors:
Yes
Schedule:
Hanover - Munich
MSN:
425-0222
YOM:
1985
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3600
Captain / Total hours on type:
400.00
Copilot / Total flying hours:
5200
Copilot / Total hours on type:
300
Aircraft flight hours:
5836
Aircraft flight cycles:
4376
Circumstances:
The aircraft took off at 0041 hrs from Hanover (EDDV) for a positioning flight to Munich (EDDM) with a crew of two pilots. The intention was to make a subsequent air ambulance flight from Munich to Kiel. During the climb the crew received the instruction for a direct flight to Munich and the clearance for a climb to Flight Level (FL) 230. The radar data showed that the aircraft turned south-east and climbed to FL230 after take-off. At 0123:45 hrs the crew made radio contact with Munich Radar. About five minutes later, the controller advised the crew that both runways were closed for snow removal, but that the southern runway would re-open in about 25-30 minutes. In response, the crew advised they would reduce the speed somewhat. The crew stated that the temperature in flight altitude had been -40 °C. At 0133:58 hrs the controller issued descent clearance to FL110. According to crew statements in this phase there were problems with the left engine. A system check indicated that the engine’s Interstage Turbine Temperature (ITT) had exceeded 900°C and the torque had reduced to zero. The crew then first worked through the memory items before "beginning with the engine failure checklist". In the presence of the BFU the crew gave their reasons for the shut-off of the engine as being the fast increase of the ITT and the decrease of the torque to zero. The crew could not give any other engine parameters like Ng per cent RPM, propeller RPM, fuel flow, oil pressure or oil temperature. The co-pilot reported via radio: "… we request to maintain FL150 … we have engine failure on the left side, call you back." At that time, the radar data showed the aircraft at FL214. As the controller asked at 0138:15 hrs if a frequency change to approach control were possible, the co-pilot answered: "... give us a minute, please, and then we report back, until we have everything secured ..." At 0143:22 hrs the co-pilot advised the controller that the engine had been "secured" and a frequency change was now possible. The crew subsequently reported that, three to five minutes later there had been brief, strong vibrations in the right engine. The crew could not state which actions they had carried out after the descent clearance and during shut-off and securing of the left engine. Both pilots stated that there was no attempt to re-start the left engine. After changing frequency to Munich Approach Control the crew was advised that runway 26L was available. The co-pilot declared emergency at 0143:48 hrs, about 25 NM away from the airport of destination, mentioning again the failure of the left engine. The controller responded by asking the crew what assistance they would require, and asked if a ten-mile approach would be acceptable. This was affirmed. At 0149:28 hrs the controller gave clearance for an ILS approach to runway 26L. At that time the radar data showed the airplane in FL78 flying with a ground speed of 210 kt to the south-east. The aircraft turned right towards the final approach and at 0151:53 hrs it reached the extended runway centre line about 17 NM prior to the runway threshold in 5,400 ft AMSL with a ground speed of 120 kt. At 0154:12 hrs the controller said: "… observe you a quarter mile south of the centre line." According to the radar data the aircraft was in 5,000 ft AMSL with a ground speed of 90 kt at that time. The co-pilot answered: "Ja, we are intercepting…". Twenty seconds later the controller gave clearance to land on runway 26L. Up until about 0157:30 hrs the ground speed varied between 80 and 90 kt. From 0157:43 hrs on, within about 80 seconds, the speed increased from 100 kt to 120 kt. Thereby, the airplane had come within 5.5 NM of the threshold of runway 26L. Up until 0200:53 hrs the airplane flew with a ground speed of 100 - 110 kt. At 0201:32 hrs ground speed decreased to 80 kt. At that time, the airplane was in 1,900 ft AMSL and about 1.5 NM away from the threshold. Up until the last radar recording at 0202:27 hrs the ground speed remained at 80 kt. The crew stated the approach was flown with Blue Line Speed. During the final approach the aircraft veered slightly to the left and tended to sink below the glidepath. Approximately 3 NM from the threshold the approach lights had become visible and the flaps and the landing gear were extended. Then the airplane veered to the left and sank below the glidepath. The co-pilot stated a decision for a go-around was made. When an attempt was made to increase power from the right engine, no additional power was available. The aircraft had lost speed and to counteract it the elevator control horn was pushed. Prior to the landing, rescue and fire fighting vehicles were positioned at readiness in the vicinity of the airport’s southern fire station. The weather was described as very windy with a light snow flurry. The fire fighters subsequently reported they had seen two white landing lights and the dim outline of an approaching aircraft. The aircraft’s bank attitude was seen to alter a number of times. Shortly before landing, the landing lights suddenly disappeared and the aircraft was no longer visible. The aircraft impacted the ground about 100 metres prior to the threshold of runway 26L. The crew turned off all the electrical systems and left the aircraft unaided. During the initial interviews by BFU and police the co-pilot repeatedly talked about a go-around the crew had intended and he had, therefore, pushed the power lever for the right engine forward. In later statements he stated that the engine power was to be increased. A few days after the accident, the BFU asked both pilots for a detailed written statement concerning the course of events. The BFU received documents with a short description of the accident in note form. The statements of the two pilots were almost identical in content and format.
Probable cause:
The following findings were identified:
- When the left engine was shut down, the propeller was not feathered,
- During the final approach, the speed for an approach with one shut-off engine was lower than the reference speed,
- The airplane veered to the left during power increase and became uncontrollable due to the lack of rudder effectiveness,
- Non-adherence to checklists during the shut-off of the engine and,
- Poor crew coordination.
Final Report:

Crash of a Yakovlev Yak-40 in Luanda

Date & Time: Jan 31, 2010 at 1513 LT
Type of aircraft:
Operator:
Registration:
D2-FES
Survivors:
Yes
Schedule:
Cabinda – Luanda
MSN:
9341431
YOM:
1973
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
34
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Cabinda, the aircraft landed on runway 25 when all three gears collapsed. The aircraft slid on its belly for few dozen metres before coming to rest by taxiway Bravo. While all 37 occupants were uninjured, the aircraft was damaged beyond repair.

Crash of an Embraer EMB-110C Bandeirante in Senador José Porfirio: 2 killed

Date & Time: Jan 25, 2010 at 1320 LT
Operator:
Registration:
PT-TAF
Survivors:
Yes
Schedule:
Belém - Senador José Porfirio
MSN:
110-103
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
12350
Captain / Total hours on type:
3887.00
Copilot / Total flying hours:
701
Copilot / Total hours on type:
265
Circumstances:
Following an uneventful flight from Belém, the crew started the descent to Senador José Porfirio-Wilma Rebelo Airport in marginal weather conditions. On approach, the crew noticed an elevation of the left engine turbine temperature. The captain reduced the power on both engines and elected to make an emergency landing when the aircraft stalled and crashed in an open field located 4 km short of runway. The captain and a passenger were killed. All eight other occupants were killed, three seriously. The aircraft was destroyed.
Probable cause:
The following findings were identified:
- Weather conditions made it difficult for the crew to locate the runway;
- The crew failed to follow the emergency procedures and was unable to keep the aircraft level;
- The captain did not feather the left propeller, which resulted in increased drag and reduced aircraft speed;
- The engine maintenance did not meet the engine manufacturer's requirements;
- No technical overhaul of the left engine had been carried out despite the fact that the 12-year calendar limit set by the manufacturer had been exceeded;
- A nipple mounted on the left propeller governor was not intended for aeronautical use;
- The poor seal caused by the improper connection allowed the pressure to drop, resulting in a loss of power on the left engine;
- Poor organizational culture by the operator, which compromised the safety of the operation;
- The company did not have an effective supervision program;
- Poor judgment on part of the captain;
- Poor aircraft maintenance.
Final Report:

Crash of a Tupolev TU-154M in Mashhad

Date & Time: Jan 24, 2010 at 0720 LT
Type of aircraft:
Operator:
Registration:
RA-85787
Survivors:
Yes
Schedule:
Abadan - Machhad
MSN:
93A971
YOM:
1993
Flight number:
TBM6437
Country:
Region:
Crew on board:
13
Crew fatalities:
Pax on board:
157
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The three engine aircraft departed Abadan for a night flight to Mashhad. Due to poor weather conditions at destination, the crew diverted to Isfahan Airport. The aircraft departed Isfahan Airport at 0535LT bound to Mashhad. While on an ILS approach in thick fog, the aircraft was in a nose high attitude when the base of the empennage struck the runway surface and separated. On impact, the undercarriage were torn off. Out of control, the aircraft slid for few dozen metres, veered off runway and came to rest with both wings partially torn off, bursting into flames. At least 46 occupants were injured while the aircraft was partially destroyed by fire. Vertical visibility was 200 feet at the time of the accident due to fog.
Probable cause:
The following findings were reported:
- The visibility was below minimums,
- The crew continued the approach despite the aircraft attitude was incorrect,
- The crew failed to initiate a go-around procedure.

Crash of a Beechcraft 65-A90 King Air in Jacmel

Date & Time: Jan 23, 2010
Type of aircraft:
Operator:
Registration:
N316AF
Flight Type:
Survivors:
Yes
MSN:
LJ-214
YOM:
1967
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was apparently completing a cargo flight from Florida. Upon landing at Jacmel Airport, the undercarriage collapsed. The twin engine aircraft went out of control, veered off runway and came to rest against trees. Both occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Beechcraft B200 Super King Air in Sioux City

Date & Time: Jan 19, 2010 at 0715 LT
Operator:
Registration:
N586BC
Flight Type:
Survivors:
Yes
Schedule:
Des Moines – Sioux City
MSN:
BB-1223
YOM:
1985
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6018
Captain / Total hours on type:
1831.00
Copilot / Total flying hours:
6892
Copilot / Total hours on type:
2186
Aircraft flight hours:
10304
Circumstances:
The pilot of the Part 91 business flight filed an instrument-flight-rules (IFR) flight plan with the destination and alternate airports, both of which were below weather minimums. The pilot and
copilot departed from the departure airport in weather minimums that were below the approach minimums for the departure airport. While en route, the destination airport's automated observing system continued to report weather below approach minimums, but the flight crew continued the flight. The flight crew then requested and were cleared for the instrument landing system (ILS) 31 approach and while on that approach were issued visibilities of 1,800 feet runway visual range after changing to tower frequency. During landing, the copilot told the pilot that he was not lined up with the runway. The pilot reportedly said, "those are edge lights," and then realized that he was not properly lined up with the runway. The airplane then touched down beyond a normal touchdown point, about 2,800 feet down the runway, and off the left side of the runway surface. The airplane veered to the left, collapsing the nose landing gear. Both flight crewmembers had previous experience in Part 135 operations, which have more stringent weather requirements than operations conducted under Part 91. Under Part 135, IFR flights to an airport cannot be conducted and an approach cannot begin unless weather minimums are above approach minimums. The accident flight's departure in weather below approach minimums would have precluded a return to the airport had an emergency been encountered by the flight crew, leaving few options and little time to reach a takeoff alternate airport. The company's flight procedures allow for a takeoff to be performed as long as there is a takeoff alternate airport within one hour at normal cruise speed and a minimum takeoff visibility that was based upon the pilot being able to maintain runway alignment during takeoff. The company's procedures did not allow flight crew to depart to an airport that was below minimums but did allow for the flight crew, at their discretion, to
perform a "look-see" approach to approach minimums if the weather was below minimums. The allowance of a "look see" approach essentially negates the procedural risk mitigation afforded by requiring approaches to be conducted only when weather was above approach minimums.
Probable cause:
The flight crew's decision to attempt a flight that was below takeoff, landing, and alternate airport weather minimums, which led to a touchdown off the runway surface by the pilot-in-command.
Final Report:

Crash of a Mitsubishi MU-2B-60 Marquise in Elyria: 4 killed

Date & Time: Jan 18, 2010 at 1405 LT
Type of aircraft:
Registration:
N80HH
Flight Type:
Survivors:
No
Schedule:
Gainesville - Elyria
MSN:
732
YOM:
1978
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2010
Captain / Total hours on type:
1250.00
Copilot / Total flying hours:
190
Aircraft flight hours:
6799
Circumstances:
On his first Instrument Landing System (ILS) approach, the pilot initially flew through the localizer course. The pilot then reestablished the airplane on the final approach course, but the airplane’s altitude at the decision height was about 500 feet too high. He executed a missed approach and received radar vectors for another approach. The airplane was flying inbound on the second ILS approach when a witness reported that he saw the airplane about 150 feet above the ground in about a 60-degree nose-low attitude with about an 80-degree right bank angle. The initial ground impact point was about 2,150 feet west of the runway threshold and about 720 feet north (left) of the extended centerline. The cloud tops were about 3,000 feet with light rime or mixed icing. The flap jack screws and flap indicator were found in the 5-degree flap position. The inspection of the airplane revealed no preimpact anomalies to the airframe, engines, or propellers. A radar study performed on the flight indicated that the calibrated airspeed was about 130 knots on the final approach, but subsequently decreased to about 95–100 knots during the 20-second period prior to loss of radar contact. According to the airplane’s flight manual, the wings-level power-off stall speed at the accident aircraft’s weight is about 91 knots. The ILS approach flight profile indicates that 20 degrees of flaps should be used at the glide slope intercept while maintaining 120 knots minimum airspeed. At least 20 degrees of flaps should be maintained until touchdown. The “No Flap” or “5 Degrees Flap Landing” flight profile indicates that the NO FLAP Vref airspeed is 115 knots calibrated airspeed minimum.
Probable cause:
The pilot's failure to maintain adequate airspeed during the instrument approach, which resulted in an aerodynamic stall and impact with terrain.
Final Report:

Crash of a Beechcraft B60 Duke in Huntsville: 2 killed

Date & Time: Jan 18, 2010 at 1345 LT
Type of aircraft:
Operator:
Registration:
N810JA
Flight Type:
Survivors:
No
Schedule:
Huntsville – Nashville
MSN:
P-591
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1600
Aircraft flight hours:
3383
Circumstances:
The multiengine airplane was at an altitude of 6,000 feet when it experienced a catastrophic right engine failure, approximately 15 minutes after takeoff. The pilot elected to return to his departure airport, which was 30 miles away, instead of diverting to a suitable airport that was located about 10 miles away. The pilot reported that he was not able to maintain altitude and the airplane descended until it struck trees and impacted the ground, approximately 3 miles from the departure airport. The majority of the wreckage was consumed by fire. A 5 1/2 by 6-inch hole was observed in the top right portion of the crankcase. Examination of the right engine revealed that the No. 2 cylinder separated from the crankcase in flight. Two No. 2 cylinder studs were found to have fatigue fractures consistent with insufficient preload on their respective bolts. In addition, a fatigue fracture was observed on a portion of the right side of the crankcase, mostly perpendicular to the threaded bore of the cylinder stud. The rear top 3/8-inch and the front top 1/2-inch cylinder hold-down studs for the No. 2 cylinder exceeded the manufacturer's specified length from the case deck by .085 and .111 inches, respectively. The airplane had been operated for about 50 hours since its most recent annual inspection, which was performed about 8 months prior the accident. The right engine had been operated for about 1,425 hours since it was overhauled, and about 455 hours since the No. 2 cylinder was removed for the replacement of six cylinder studs. It was not clear why the pilot was unable to maintain altitude after the right engine failure; however, the airplane was easily capable of reaching an alternate airport had the pilot elected not to return to his departure airport.
Probable cause:
The pilot's failure to divert to the nearest suitable airport following a total loss of power in the right engine during cruise flight. Contributing to the accident was the total loss of power in the right engine due to separation of its No. 2 cylinder as a result of fatigue cracks.
Final Report: